E-cigarettes: Potential gateway to tobacco-smoking?

November 19, 2013
| by Denise Heady

Electronic cigarettes have been gaining attention and popularity worldwide — sales for these high-tech devices are well over a billion dollars and steadily increasing. A recent report from the Centers for Disease Control and Prevention found that in just one year, from 2011 to 2012, e-cigarette use among middle and high school students nearly doubled, a fact that troubles many medical professionals because 90 percent of all smokers start when they're teenagers.

The reputed benefits of e-cigarettes have been widely debated, with manufacturers and proponents saying the devices can help wean smokers from cigarettes and with medical experts warning that more research is needed before the products can be labeled as true smoking-cessation devices. City of Hope's Brian Tiep, M.D., director of pulmonary rehabilitation and smoking cessation, and Rachel Dunham, M.S.N., nurse practitioner for smoking cessation and lung cancer screening, sat down to discuss the public health concerns regarding the devices and why the medical community is wary of e-cigarettes.

What are the components of an e-cigarette?

Tiep: E-cigarettes are high-tech devices that deliver nicotine and other chemicals. Components of an e-cigarette include an LED (light-emitting diode), microcomputer, battery, switch and a liquid cartridge. When the user breathes in while using the device, the liquid is heated and emits a vapor. This vapor is inhaled. The liquid cartridge contains a mixture of propylene glycol, flavorants and often nicotine in varying concentrations.

Because e-cigarettes are not FDA regulated, the manufacturer is not required to list the ingredients. There is no consistency from brand to brand. Furthermore, the nicotine content within the same brand may vary. Some people who never smoked tobacco cigarettes (including kids) are now smoking e-cigarettes, some of which contain nicotine.

What's the background of e-cigarettes?

Tiep: The tobacco industry is losing market share on tobacco cigarettes. At the same time, the e-cigarette market is increasing by about the same amount. Thus, the tobacco industry has decided to get into the business of e-cigarettes. Its track record is to sell a product that is lethal if used as directed. Thus, the claims about safety should be questioned. Nicotine, the agent of addiction, is now included in e-cigarettes. Once a person becomes addicted to the nicotine, there are changes in their brains that make them they crave nicotine. This could lead to future tobacco use.

Dunham: E-cigarettes are fairly new, and we need long-term studies to determine their safety and health effects. We do know that some of the products used in e-cigarettes are potentially carcinogenic (cancer-causing).

Do you think electronic cigarettes are an effective way for smokers to quit the habit?

Tiep: Some people have been able to quit smoking using e-cigarettes. We do not know how many of those people might relapse, but we do know that some will smoke both tobacco and e-cigarettes. We don’t know the long-term efficacy of e-cigarettes as a means to quitting smoking. We also don’t know how effective they are in comparison to standard FDA-approved methods designed for that purpose.

So we do not really have full answers to critical questions.

We do find that some of our patients are reluctant to take FDA-approved medications, thinking that medications can be harmful, yet they’re smoking cigarettes, which has been proven to be a lethal addiction. We find some patients feel safe in buying e-cigarettes because after all: “Isn’t fruit flavored vapor safe?" But we really don’t know.

Many patients who are unwilling to purchase medications to treat nicotine withdrawal will buy e-cigarettes. Actually some will be successful in quitting or cutting back; we just don’t know for how long.

Many people are concerned that e-cigarettes are being highly marketed to the youth. What’s your take on that?

Dunham: Because e-cigarettes are high-tech devices that deliver chemicals, they are very attractive to children and youth. Moreover, these companies are obviously making an effort to market toward our youth. I have two boys, and both of them have received phone calls on their cell phone asking if they would like a sample of e-cigarettes. They [e-cigarette companies] have made a tremendous effort to market to our kids. A vapor shop just opened across the street from my son’s high school in Long Beach. Noting that e-cigarettes are becoming popular among high school students and young adults, it is reminiscent of a tobacco industry that has been marketing to youth for many years but has denied it all along. As nicotine delivery devices, they potentially addict youth to nicotine at a vulnerable age. This is one of several concerns we have with e-cigarettes. We don’t know if it’s a potential gateway to tobacco smoking.

Tiep: The tobacco industry has a history in this kind of business. For example, they had a lot of influence over candy cigarettes, which were made for children, but also encouraged them to smoke because after all, “that’s the adult thing to do.” Joe Camel, the cartoon character in cigarette advertising, is a common example of marketing to kids. As our youth struggle to grow into independent adults, they are vulnerable to these kinds of marketing strategies.

What’s the safest way to quit smoking?

Dunham: Standard nicotine replacement therapy, Varenicline or Buproprion, are all FDA-approved methods that have been proved to be safe. In addition, smoking-cessation experts work with smokers to break habit links that are tied to smoking. Thus smoking-cessation programs, which prevent withdrawal symptoms, break habits and provide continuous and regular support, are the most effective at present.

When a person smokes a cigarette, the smoke goes to their lungs, heart and brain within seven seconds — less than two heartbeats. This creates a rush that releases dopamine, a powerful neurotransmitter involved in pleasure and rapid reassurance. Every time a person smokes, they get this dopamine release that brings them back to center. When they don’t smoke, they get withdrawal symptoms, causing them to crave nicotine, become irritable and agitated. So there is a major dichotomy between the pleasure of smoking and the uncomfortable sensation of withdrawal.

Do you think e-cigarettes can be regulated to become a smoking-cessation device?

Tiep: If we can make an e-cigarette that is well-controlled by a pharmaceutical company, yes. They’re monitored, and they’ll be checked out regularly to ensure safety and efficacy. Then we would have a good chance that e-cigarettes could be included among other FDA-approved tobacco-cessation methods used to prevent withdrawal symptoms.